Question

A nurse is caring for a client receiving combination chemotherapy through an implanted infusion port. The client reports new onset of severe fatigue, and lab results show a hemoglobin level of 6 g/dL and a platelet count of 35,000/mm³. What is the nurse's priority action?

Answer 1

Correct Answers:

Hold the chemotherapy administration and notify the oncologist immediately.

Rationale :

♦️ The client has a hemoglobin of 6 g/dL, which indicates severe anemia and markedly reduced oxygen-carrying capacity.

♦️ The platelet count of 35,000/mm³ represents significant thrombocytopenia and creates a substantial risk for bleeding.

♦️ These findings strongly suggest chemotherapy-induced bone marrow suppression, also called myelosuppression.

♦️ Continuing chemotherapy could worsen the client's anemia and thrombocytopenia, increasing the risk of tissue hypoxia, hemorrhage, and other serious complications.

♦️ The client's new severe fatigue is consistent with the profound anemia and should be treated as a significant clinical deterioration.

♦️ The nurse should hold the chemotherapy until the oncology provider evaluates the laboratory abnormalities and determines whether treatment can safely continue.

♦️ The oncologist may order interventions such as packed red blood cell transfusion, platelet support, treatment delay, or chemotherapy dose adjustment based on the overall clinical picture.

♦️ Therefore, the priority is to prevent further marrow suppression and obtain immediate oncology evaluation.

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Answer 2

Correct Answers:

Filgrastim (Neupogen)

Rationale :

✏️ Filgrastim is a granulocyte colony-stimulating factor (G-CSF) used to stimulate the bone marrow to produce more neutrophils, a type of white blood cell.

✏️ It is commonly used in clients receiving myelosuppressive chemotherapy who develop or are at high risk for neutropenia.

✏️ Increasing neutrophil production helps shorten the duration and severity of chemotherapy-induced neutropenia.

✏️ Improving the absolute neutrophil count (ANC) reduces the client's vulnerability to serious bacterial and fungal infections.

✏️ The nurse should monitor the client's CBC with differential and ANC to evaluate the response to filgrastim.

✏️ A common adverse effect of filgrastim is bone pain, caused by increased activity within the bone marrow.

✏️ Filgrastim is generally timed separately from cytotoxic chemotherapy because administering it too close to chemotherapy can expose rapidly dividing marrow cells to increased cytotoxic effects.

✏️ Therefore, filgrastim (Neupogen) is the medication the nurse should anticipate when the goal is to increase white blood cell/neutrophil production.

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Answer 3

Correct Answers:

Malignant tumors may spread to other organs or tissues

Rationale :

✨ Malignant tumors are cancerous growths that have the ability to invade surrounding tissues.

✨ Malignant cells can break away from the original tumor and travel through the bloodstream or lymphatic system.

✨ The spread of malignant cells from the primary tumor to another location is called metastasis.

✨ Common metastatic sites for breast cancer can include the lymph nodes, bones, lungs, liver, and brain.

✨ Malignant tumors are generally less well differentiated than benign tumors, meaning their cells may appear and function less like the normal tissue of origin.

✨ Unlike many benign tumors, malignant tumors are typically poorly encapsulated or nonencapsulated, allowing them to infiltrate nearby structures.

✨ Their ability to invade and metastasize is one of the most important characteristics distinguishing malignant tumors from benign tumors.

✨ Therefore, telling the client that malignant tumors may spread to other organs or tissues correctly explains a major difference between malignant and benign tumors.

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Answer 4

Correct Answers:

Vitamin B12 must be administered by monthly parenteral injections to prevent irreversible neurological damage.

Rationale :

✳️ Pernicious anemia results from autoimmune destruction of gastric parietal cells and deficiency of intrinsic factor, which is necessary for normal vitamin B12 absorption.

✳️ Without adequate intrinsic factor, the client cannot efficiently absorb dietary vitamin B12 through the usual gastrointestinal pathway.

✳️ Vitamin B12 is essential for normal red blood cell formation, DNA synthesis, and neurologic function.

✳️ Untreated deficiency can produce neurologic manifestations such as paresthesias, numbness, impaired balance, weakness, and cognitive changes.

✳️ Prolonged vitamin B12 deficiency can cause irreversible neurologic injury, making consistent replacement therapy extremely important.

✳️ Traditional nursing-exam teaching emphasizes lifelong parenteral vitamin B12 replacement, often beginning with more frequent doses followed by monthly maintenance injections.

✳️ The client's hematologic abnormalities may improve relatively quickly with treatment, but neurologic recovery can take longer, especially when deficiency has been prolonged.

✳️ Therefore, among the options provided, monthly parenteral vitamin B12 replacement is the best answer for effective long-term management of pernicious anemia.

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Answer 5

Correct Answers:

Engraftment indicates a complication of the transplant where the body rejects the bone marrow.

Rationale :

💎 Engraftment occurs after a hematopoietic stem cell or bone marrow transplant when the transplanted stem cells successfully establish themselves in the recipient's bone marrow.

💎 The transplanted stem cells begin producing new white blood cells, red blood cells, and platelets.

💎 A key early sign of successful engraftment is a sustained increase in the absolute neutrophil count (ANC).

💎 Recovery of neutrophils improves the client's ability to fight infection, which is especially important after the profound immunosuppression associated with transplantation.

💎 As red blood cell production recovers, the client's anemia, fatigue, and transfusion requirements can gradually improve.

💎 Recovery of platelet production decreases the client's risk for bleeding and hemorrhage.

💎 The healthcare team closely monitors CBC values and clinical status to determine whether engraftment is occurring successfully.

💎 Therefore, the goal of engraftment is for the transplanted hematopoietic cells to establish functioning marrow and resume healthy blood cell production.

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Answer 6

Correct Answers:

Advise the client to avoid vitamin C intake as it can interfere with iron absorption.

Rationale :

⚽ Intravenous iron can cause hypersensitivity reactions, including rare but potentially life-threatening anaphylactic reactions.

⚽ The nurse should closely observe the client during administration, particularly when the infusion is initiated, because reactions can develop rapidly.

⚽ Warning manifestations can include dyspnea, wheezing, chest tightness, hypotension, tachycardia, urticaria, flushing, and facial or airway swelling.

⚽ The nurse should ensure that appropriate emergency medications and resuscitation equipment are readily available according to facility protocol.

⚽ If signs of a serious hypersensitivity reaction develop, the iron infusion should be stopped immediately, and emergency treatment should be initiated according to protocol.

⚽ The client should also be observed for an appropriate period after administration, according to the specific IV iron product and facility guidelines.

⚽ Monitoring vital signs and the client's overall clinical status helps identify hypotension and other infusion-related reactions promptly.

⚽ Therefore, close monitoring for an allergic or hypersensitivity reaction is the priority safety intervention during IV iron therapy.

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Answer 7

Correct Answers:

I will choose soft, moist foods like mashed potatoes or scrambled eggs

Rationale :

🎯 Stomatitis is inflammation and ulceration of the oral mucosa that commonly occurs as an adverse effect of chemotherapy.

🎯 Soft, moist foods are easier to chew and swallow and are less likely to traumatize painful oral tissues.

🎯 Foods such as mashed potatoes, scrambled eggs, oatmeal, yogurt, pudding, and soft cooked foods can provide nutrition while minimizing oral irritation.

🎯 Adding moisture with sauces, gravies, or broth can make foods easier and more comfortable to swallow.

🎯 Foods and beverages are generally better tolerated when served cool or at room temperature rather than extremely hot.

🎯 Adequate nutrition is important because severe stomatitis can reduce oral intake and contribute to weight loss, dehydration, and malnutrition.

🎯 The client should maintain gentle oral hygiene and follow prescribed mouth-care measures to reduce discomfort and infection risk.

🎯 Therefore, choosing soft, moist, nonirritating foods demonstrates correct understanding of dietary management for chemotherapy-induced stomatitis.

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Answer 8

Correct Answers:

The client is experiencing tissue hypoxia due to blocked blood flow from, sickled cells, requiring urgent oxygenation and hydration.

Rationale :

🧿 During a vaso-occlusive crisis, sickled red blood cells become rigid and obstruct small blood vessels, reducing blood flow to tissues.

🧿 The vascular obstruction causes tissue ischemia and hypoxia, which are major causes of the client's severe pain.

🧿 The client's low oxygen saturation is particularly concerning because hypoxemia can promote additional red blood cell sickling and worsen the crisis.

🧿 Supplemental oxygen is indicated when hypoxemia is present, with respiratory status and oxygen saturation monitored closely.

🧿 Hydration helps improve circulating volume and decrease blood viscosity, which can support blood flow through affected vessels when dehydration is present.

🧿 Severe vaso-occlusive pain requires rapid and adequate analgesia, commonly with opioids for severe pain, rather than delaying treatment because of concerns about drug-seeking.

🧿 The nurse should also assess for serious complications such as acute chest syndrome, particularly when hypoxemia, chest symptoms, fever, or respiratory deterioration occurs.

🧿 Therefore, tissue hypoxia from microvascular obstruction by sickled cells is the priority hypothesis guiding immediate care.

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Answer 9

Correct Answers:

Persistent cough or hoarseness
Sore that does not heal
A new lump or thickening in the breast or elsewhere

Rationale :

✅ Persistent cough or hoarseness

🍊 A persistent cough or hoarseness is one of the classic seven warning signs of cancer.

🍊 A cough that does not resolve may indicate abnormalities involving the lungs or respiratory tract.

🍊 Persistent hoarseness can occur when a lesion affects the larynx, vocal cords, or surrounding structures.

🍊 These symptoms are especially concerning when they are new, persistent, progressive, or unexplained.

🍊 Associated manifestations such as hemoptysis, unexplained weight loss, difficulty swallowing, or persistent shortness of breath increase concern.

🍊 Many noncancerous disorders can also cause coughing and hoarseness, so the finding does not automatically mean the client has cancer.

🍊 The purpose of recognizing warning signs is to encourage prompt medical evaluation and early detection.

🍊 Therefore, persistent cough or hoarseness should be included in the client's cancer-warning-sign education.

✅ Sore that does not heal

🍊 A sore that does not heal is another classic cancer warning sign.

🍊 Normal wounds should progress through predictable stages of tissue repair and healing.

🍊 A persistent lesion may indicate abnormal cellular growth, particularly involving the skin or oral tissues.

🍊 The client should pay attention to sores that repeatedly bleed, crust, ulcerate, or fail to close.

🍊 Persistent oral lesions are particularly important to evaluate in clients with risk factors for oral cancer.

🍊 Skin lesions that fail to heal may also occur with certain forms of skin cancer.

🍊 Early evaluation allows suspicious lesions to be examined and, when appropriate, biopsied.

🍊 Therefore, a nonhealing sore should always be included among the traditional warning signs of cancer.

✅ A new lump or thickening in the breast or elsewhere

🍊 A new lump or thickening is a classic warning sign requiring further evaluation.

🍊 A lump can represent abnormal tissue growth in the breast, lymph nodes, testicles, soft tissues, or other areas.

🍊 Breast lumps are particularly important because some may represent breast malignancy, although many breast masses are benign.

🍊 Cancerous masses may be hard, irregular, fixed, or painless, but characteristics vary considerably.

🍊 Clients should not assume that a painless lump is harmless because some malignant tumors cause little or no pain initially.

🍊 Any persistent or unexplained new mass should receive appropriate clinical evaluation.

🍊 Early investigation can allow malignancies to be detected at an earlier stage when treatment may be more effective.

🍊 Therefore, new lumps or areas of thickening are important warning signs to teach.

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Answer 10

Correct Answers:

Male children have a 50% chance of having hemophilia, while female children have a 50% chance of being carriers but usually do not have the disease.

Rationale :

🌸 Hemophilia A and B are typically inherited as X-linked recessive disorders.

🌸 A carrier mother has one normal X chromosome and one X chromosome containing the hemophilia-associated variant.

🌸 The unaffected father has a normal X chromosome and Y chromosome.

🌸 Each son receives his Y chromosome from his father and one X chromosome from his mother.

🌸 A son therefore has a 50% chance of receiving the affected X chromosome, which would result in hemophilia.

🌸 Each daughter receives the father's normal X chromosome and one of the mother's X chromosomes.

🌸 Consequently, each daughter has a 50% chance of being a carrier, while daughters in this specific parental combination generally do not have classic hemophilia.

🌸 Therefore, the correct teaching is 50% of sons may have hemophilia, and 50% of daughters may be carriers, with each pregnancy representing an independent event.

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Custom N331 Exam 1 FA26- Minton Assessment

No.

1 :
A nurse is caring for a client receiving combination chemotherapy through an implanted infusion port. The client reports new onset of severe fatigue, and lab results show a hemoglobin level of 6 g/dL and a platelet count of 35,000/mm³. What is the nurse's priority action?

2 :
Which of the following medication will the nurse anticipate to administer to increase white blood cell production for a client with cancer?

3 :
A 68 year old female that is scheduled for a biopsy of a lump in the right breast. She asks the nurse about the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?

4 :
A nurse is educating a client with pernicious anemia about vitamin B12 treatment. Which teaching point is most important to include to ensure effective management of the condition?

5 :
After a bone marrow aspiration in a patient with leukemia, the nurse explains the goal of engraftment to the patient. Which statement best describes this goal?

6 :
A nurse is preparing to administer intravenous iron therapy to a client with iron deficiency anemia who cannot tolerate oral supplements. Which nursing action is the priority to ensure safe administration?

7 :
A nurse is educating a client who developed stomatitis from chemotherapy about dietary modifications. Which statement by the client indicates an understanding of appropriate foods and drinks to manage stomatitis?

8 :
A client with sickle cell anemia is admitted to the emergency department during a vaso-occlusive crisis. The nurse notes severe pain, tachycardia, and low oxygen saturation. Which nursing hypothesis should be prioritized to guide immediate care?

9 :
A nurse is educating patients on recognizing the seven warning signs of cancer to promote early detection. Which of the following signs should the nurse include in the teaching? (Select all that apply)

10 :
A mother is a carrier of the hemophilia gene, and the father does not have the defective gene. Which statement best explains the risk for their children developing hemophilia?

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Custom N331 Exam 1 FA26- Minton Assessment

No.

1 : A nurse is caring for a client receiving combination chemotherapy through an implanted infusion port. The client reports new onset of severe fatigue, and lab results show a hemoglobin level of 6 g/dL and a platelet count of 35,000/mm³. What is the nurse's priority action?

2 : Which of the following medication will the nurse anticipate to administer to increase white blood cell production for a client with cancer?

3 : A 68 year old female that is scheduled for a biopsy of a lump in the right breast. She asks the nurse about the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?

4 : A nurse is educating a client with pernicious anemia about vitamin B12 treatment. Which teaching point is most important to include to ensure effective management of the condition?

5 : After a bone marrow aspiration in a patient with leukemia, the nurse explains the goal of engraftment to the patient. Which statement best describes this goal?

6 : A nurse is preparing to administer intravenous iron therapy to a client with iron deficiency anemia who cannot tolerate oral supplements. Which nursing action is the priority to ensure safe administration?

7 : A nurse is educating a client who developed stomatitis from chemotherapy about dietary modifications. Which statement by the client indicates an understanding of appropriate foods and drinks to manage stomatitis?

8 : A client with sickle cell anemia is admitted to the emergency department during a vaso-occlusive crisis. The nurse notes severe pain, tachycardia, and low oxygen saturation. Which nursing hypothesis should be prioritized to guide immediate care?

9 : A nurse is educating patients on recognizing the seven warning signs of cancer to promote early detection. Which of the following signs should the nurse include in the teaching? (Select all that apply)

10 : A mother is a carrier of the hemophilia gene, and the father does not have the defective gene. Which statement best explains the risk for their children developing hemophilia?

1 :
A nurse is caring for a client receiving combination chemotherapy through an implanted infusion port. The client reports new onset of severe fatigue, and lab results show a hemoglobin level of 6 g/dL and a platelet count of 35,000/mm³. What is the nurse's priority action?

2 :
Which of the following medication will the nurse anticipate to administer to increase white blood cell production for a client with cancer?

3 :
A 68 year old female that is scheduled for a biopsy of a lump in the right breast. She asks the nurse about the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?

4 :
A nurse is educating a client with pernicious anemia about vitamin B12 treatment. Which teaching point is most important to include to ensure effective management of the condition?

5 :
After a bone marrow aspiration in a patient with leukemia, the nurse explains the goal of engraftment to the patient. Which statement best describes this goal?

6 :
A nurse is preparing to administer intravenous iron therapy to a client with iron deficiency anemia who cannot tolerate oral supplements. Which nursing action is the priority to ensure safe administration?

7 :
A nurse is educating a client who developed stomatitis from chemotherapy about dietary modifications. Which statement by the client indicates an understanding of appropriate foods and drinks to manage stomatitis?

8 :
A client with sickle cell anemia is admitted to the emergency department during a vaso-occlusive crisis. The nurse notes severe pain, tachycardia, and low oxygen saturation. Which nursing hypothesis should be prioritized to guide immediate care?

9 :
A nurse is educating patients on recognizing the seven warning signs of cancer to promote early detection. Which of the following signs should the nurse include in the teaching? (Select all that apply)

10 :
A mother is a carrier of the hemophilia gene, and the father does not have the defective gene. Which statement best explains the risk for their children developing hemophilia?